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Applications Will Be Processed When Submitted Properly Complet op�gFe9'+o Sign The Appbca Ion. <br /> ' oR•oFFlcEusE: APPLICATION 01980 <br /> (For Non-Transferable,Revocable, Susp a`6le) ,]A� 3 PU,(t(1P&WELL Q <br /> ENVIRONMENTAL HEALTH PERMIT vtpy i_OC, <br /> WATER QUALITY N J(lil DISTRICT <br /> ' /(COMPLETE IN TRIPLICATE) �Att,,i1F�CCtLT� tnUnUanf����000��` <br /> Application is hereby madeto theSen Joaquin Local Health Districtfora permitto constructand/or inst97Ehework,herein described.This application is-4— <br /> made in compliance with San Joaquin Count(Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_;yz E !Ci(l�+e �� City/town <br /> �yA-42 WOO—AZ <br /> Owner's Name Phone <br /> Address �J 95'U �• /(ff-� IeA <br /> + r City <br /> Contractor's Name f/BaJL llJ1L License#,a Business Phone—Ski//D <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yesy� No <br /> ' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ' DISTANCE TO NEAREST: Septic Tank®© Sewer Lines Pit Privy <br /> Sewage Disposal Fleld Z1:229" Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well e", � <br /> INTENDED USE TYPE OF WELL <br /> ' ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Die. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> rd IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: - Q <br /> ' PUMP INSTALLATION: Contractor4�--'+11�62� <br /> Type of Pu;rtP H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> S <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> ' Contractor's hiring or subcontracting signature certifies the following:"I certify that In the performance of the work forwhich this <br /> permit Is issued, I shall employ persons subject to workman's compensation laws of California" <br /> 1 will call for a Grout In ctlonn prior to grouting and a final Inspe�cttii�on..�� �y ems^ <br /> ' <br /> Signed X � �� Title: c�''-`t".o`,.'-- Date: ,�'�D•—'Ira <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PART NT USE ONLY <br /> PHASEI (f <br /> Application Accepted By ®� Date <br /> Additional Comments: <br /> ' Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t 6 Received By January 31 ❑ July 1 a ReceivedByJuly 31 <br /> ' BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED' <br /> GATE DATE REMITTED AMOUNT <br /> FEE <br /> ' LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> ' Received by - Date Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20M STOCKTON,CA 9540 <br />